HomeMy WebLinkAboutMiscellaneous - 24 HIGHLAND TERRACE 4/30/2018 (2)CHECKLIST FOR CARBON MONOXIDE
Location of Incident:
Date of incident
QUICK CHECKLIST OF OCCUPANTS
Ileadache yes no, Fatigue yes no-�
Nausea yes no 4 Dizziness yes no_
Confusion yes no C�
Are any members of the household feeling ill? yes noL
Do the residents feel better away from the house? yes no
Since the detector's alarm went off, what have you done?
Shut- off carbon monoxide sources yes no�
If yes which sources
Let in fresh air? yes no
If yes how did you let the air in
Mow long did you let the air in
PPM reading ambient outside the dwellingN�
I lighest PPM reading in the dwelling /p FItWf
Carbon monoxide detector present? yesc>/— no
.t'f yes list the number of detetors locations and make, and serial number of each below.
2..
3.
4.
Which detector(s) by number above activated? -0f
SOURCE CI-JECKLIS'f LOCATION PPM READING
Chimney clogged flue, blocked opening
Fireplace(s) Natural gas, LPG, Wood(indicate type for each fireplace)
157Flab r ,!n Ppm
Gas Appliance (if Gas Company on Scene they can perform this check)
(IF MORE THAN 1 OF TI -IE FOLLOWING APPLIANCES LIST EACH ADDITIONAL
ON TME COMMENTS PAGE WITH ITS LOCATION, AND PPM READING)
refrigerator
stove
vent over stove
clothes dryer
water heater
furnace
Oil burner
car garage
Entranceway from garage to house
Gell aA G q -s
d
Name of individual operating the. CO monitor �
Person completing the Checklist r17'c
Ai"iDOla) ER_T_IRE
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